How to avoid lacrimal gland compromise and dry eye from Botox treatment

Dr Tim Pearce recently explored how to avoid causing eyelid ptosis with botulinum toxin treatments and how to avoid lateral rectus palsy and double vision from Botox treatment, so the next potential side effect he wants to share is how to avoid dry eye.

This may sound like a minor inconvenience and a mild side effect. Still, anyone with dry eye experience following an accidental eye injury, including Dr Tim, will know that it is miserable and not in the least bit trivial. It can disrupt your day-to-day function, often involving tedious treatment with daily eye drops for at least a month. Your patients will not thank you if you cause this complication (or other eye-related problems) following botulinum toxin or Botox® injections. Thankfully, dry eye is rare, and by minimising a few risks, it is an easily avoided treatment complication.

In this blog, Dr Tim Pearce will discuss the anatomy and position of the lacrimal gland, safe injection techniques, dosing and placement of botulinum toxin to avoid causing dry eye, and other side effects including lower lid “ledges”, lower lid descent, and ectropion eyelid.

If you want to elevate your botulinum toxin injection skills, with a proven step-by-step guide to delivering consistently stunning results and minimising the most common complications, find out more about the Pro Tox system from Dr Tim Pearce.

The position of the lacrimal gland

To understand what causes dry eye, we first need to know the location of the lacrimal gland involved in lacrimal fluid or tear production to maintain moisture levels on the eye’s surface.

The lacrimal gland is positioned near the suture between the zygomatic bone and the frontal bone but may be more superior than illustrated in the 3D image in some individuals. Importantly, it is in an area where aesthetic clinicians inject for botulinum toxin anti-wrinkle treatments.

How can you affect the lacrimal gland when injecting Botox?

There are several anatomical features and safety margins that aesthetic clinicians can use to mitigate the risk of harm to the lacrimal gland and avoid dry eye complications.

Firstly, regard the orbital rim as a primary boundary to check when marking out your injection points for treating lateral canthal lines. Always leave a 1.5cm margin away from the orbital rim to ensure you are nowhere near the lacrimal gland.

A second principle safety measure relates to the depth of your injections and applies to treating both lateral canthal lines and underneath the eyebrow. The target, the orbicularis oculi muscle is a superficial muscle – positioned underneath a thin layer of skin with a fat layer beneath. These defined tissue layers and superficial injection techniques can be used to shield and defend the eye and lacrimal gland from botulinum toxin with placement outside of the tissue plane that could be affected. By being superior to the lacrimal gland when injecting underneath the eyebrow, you will be shielded by the muscle, a layer of fat, and the orbital septum meaning you are much less likely to cause a dry eye.

How to avoid other side effects when injecting Botox around the eyes?

Whilst exploring injecting botulinum toxin around the eye, it seems worthwhile to touch on other unwanted side effects and rare complications that may present in patients if risks are not mitigated.

Overtreating the lower lateral aspect of the eye causes a “ledge”

When treating lateral canthal lines, if you treat a little too heavily in the lower lateral aspect of the eye, it can cause a relaxation of the orbicularis oculi muscle, so it meets the transition point of the zygomaticus major muscle as it pulls up on smiling, causing a little “ledge” or shadow in the lower lid area.

The key to avoidance is dose. By reducing the dose of botulinum toxin on the lower aspect of the eyelid – a two-unit dose of Botox is adequate for most patients – you can achieve a more than satisfactory result to the crow’s feet without causing the ledge effect.

Overtreating under the eye causes the descent of the lower lid

This side effect, caused by overtreatment with botulinum toxin underneath the eye, especially in more mature patients, has been described as “looking a bit like a psycho” because the descent of the lower lid can cause a wide-eyed appearance, especially when smiling, which makes the individual look a little scary.

As we age, we naturally lose collagen and elastin, meaning the area underneath the eye is held together by the muscle. If you relax that muscle, the lower lid will descend, looking unattractive, even though lines and wrinkles will have resolved.

This common side effect is easily avoided by appropriate patient selection. Only choose patients who have a good snap test – pulling the lower eyelid downward and observing how quickly it snaps back to the eye – demonstrating the presence of plenty of collagen and elastin. Use low botulinum toxin doses for treatment.

Learn how to get a great result with Botox in older patients.

Poor patient selection could cause ectropion eyelid

An ectropion eyelid is a very rare but reported complication from botulinum toxin treatment.

Most notably in medicine, we see ectropion eyelid occurring in geriatric patients, including those with no history of Botox treatment, caused by a deterioration in skin quality impacting the ability of the undereye tissue to hold itself in position, leading to a show of the pink area of the lower eyelid.

Treating a patient with botulinum toxin, who already has signs of poor skin quality under the eye could initiate this side effect because the orbicularis oculi muscle holds the lower eyelid against the lower part of the globe; as you relax it to try and soften a wrinkle, it falls outward potentially causing an ectropion eyelid if there is a lack of other tissue support. Appropriate patient selection and the avoidance of high botulinum toxin doses in the lower lid or the avoidance of treatment in this area altogether are key to mitigating the risk of this complication.

Only a small minority of patients benefit from Botox treatment underneath the eye; it sometimes helps younger patients to soften very crinkly skin using very low dose treatment. However, most patients have lines under their eyes caused by the zygomatic muscles and the cheek elevators squeezing the lower eyelid skin during a smile. Treating orbicularis oculi for this indication will have a minimal effect and may make it worse.

Read more blogs from Dr Tim and discover if you should inject Botox under the eye for fine lines and wrinkles, jelly roll and eye-widening.

If you have any questions or topics for discussion, you can find Dr Tim Pearce on Instagram.

Botox® is a registered trademark of Allergan Aesthetics plc.

Introducing Pro Tox

If you have been waiting to stop second-guessing yourself during botulinum toxin treatments, deliver flawless results that keep patients coming back, unlock advanced techniques, minimise complications, and finally feel like the expert injector you know you can be; find out more about the Pro Tox system from Dr Tim Pearce.

With Pro Tox, you will have the tools and comprehensive training to deliver consistently flawless results that keep your patients loyal, happy, and referring their friends - without needing review appointments or competing on price.

Pro Tox Course

Aesthetics Mastery Show

DRY EYES AFTER BOTOX – How to Avoid & treat This Botox Complication

Dr Tim says:

“In this video I’m sharing crucial insights on how to avoid causing dry eye during Botox treatments. Dry eye might sound like a minor inconvenience, but having experienced it personally after an eye injury, I can assure you—it’s far from trivial. It can severely disrupt daily life, and as practitioners, it’s our responsibility to minimize risks for our patients. “

Watch the full Aesthetics Mastery Show here.

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BOTOX (Botulinum Toxin) eLearning Courses

If you want to increase your confidence in botulinum toxin injections, or learn how to avoid and handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

• BOTOX® Foundation Course
• Botulinum Toxin Complications Mastery

Both give CPD and certificates on completion.

In addition, browse our FREE downloadable resources on complications.

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.